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1 bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 14 October 2015 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Bipolar disorder No additional information 2 Support for people with bipolar disorder Use this pathway in conjunction with the NICE pathway on service user experience in adult mental health to improve the experience of care for adults with bipolar disorder using mental health services, and for adults, children and young people: promote a positive recovery message from the point of diagnosis and throughout care build supportive and empathic relationships as an essential part of care. Follow the recommendations in general principles of care for young people with psychosis and schizophrenia in the NICE pathway on psychosis and schizophrenia to improve the experience of care for children and young people with bipolar disorder. Information and support Consider identifying and offering assistance with education, financial and employment problems that may result from the behaviour associated with bipolar disorder, such as mania and hypomania. If the person with bipolar disorder agrees, this could include talking directly with education staff, creditors and employers about bipolar disorder and its possible effects, and how the person can be supported. Encourage people with bipolar disorder to develop advance statements while they are stable, in collaboration with their carers if possible. Explain and discuss making a lasting power of attorney with adults with bipolar disorder and their carers if there are financial problems resulting from mania or hypomania. Alcohol, tobacco, prescription and non-prescription medication and illicit drugs Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the person, and their carer if appropriate. Explain the possible interference of these substances with the therapeutic effects of prescribed medication and psychological interventions. Page 3 of 10

4 Treatment and support for specific populations People from black, Asian and minority ethnic groups Follow the recommendations in race, culture and ethnicity in the NICE pathway on psychosis and schizophrenia when working with people with bipolar disorder from black, Asian and minority ethnic groups. Women of childbearing potential See the NICE pathway on antenatal and postnatal mental health for guidance on the management of bipolar disorder during pregnancy and the postnatal period and in women and girls of childbearing potential. People with a learning disability Ensure that people with bipolar disorder and a coexisting learning disability are offered the same range of treatments and services as other people with bipolar disorder. Older people Ensure that older people with bipolar disorder are offered the same range of treatment and services as younger people with bipolar disorder. People with coexisting mental health disorders Offer people with bipolar disorder and coexisting disorders such as personality disorder, attention deficit hyperactivity disorder, anxiety disorders or substance misuse treatment in line with the relevant NICE pathway, in addition to their treatment for bipolar disorder, be alert to the potential for drug interactions and use clinical judgement. See the NICE pathways on: personality disorders attention deficit hyperactivity disorder generalised anxiety disorder psychosis with coexisting substance misuse. Page 4 of 10

5 People with rapid cycling bipolar disorder Offer people with rapid cycling bipolar disorder the same interventions as people with other types of bipolar disorder because there is currently no strong evidence to suggest that people with rapid cycling bipolar disorder should be treated differently. Quality standards The following quality statement is relevant to this part of the pathway. Bipolar disorder, psychosis and schizophrenia in children and young people quality standard 8. Education and employment-related training 3 Support for carers Assessment Offer carers of people with bipolar disorder an assessment (provided by mental health services) of their own needs and discuss with them their strengths and views. Develop a care plan to address any identified needs, give a copy to the carer and their GP and ensure it is reviewed annually. Advise carers about their statutory right to a formal carer's assessment provided by social care services and explain how to access this. Providing and sharing information Give carers written and verbal information in an accessible format about: diagnosis and management of bipolar disorder positive outcomes and recovery types of support for carers role of teams and services getting help in a crisis. When providing information, offer the carer support if necessary. Page 5 of 10

6 As early as possible negotiate with the person with bipolar disorder and their carers about how information about the person will be shared. When discussing rights to confidentiality, emphasise the importance of sharing information about risks and the need for carers to understand the person's perspective. Foster a collaborative approach that supports both people with bipolar disorder and their carers, and respects their individual needs and interdependence. Review regularly how information is shared, especially if there are communication and collaboration difficulties between the person and their carer. Decision-making Include carers in decision-making if the person agrees. Education and support Offer a carer-focused education and support programme, which may be part of a family intervention for bipolar disorder, as early as possible to all carers. The intervention should: be available as needed have a positive message about recovery. Safeguarding Identify children, young people and adults at risk of abuse or neglect who are dependent on, living with or caring for a person with bipolar disorder and: review the need for an assessment according to local safeguarding procedures for children or adults as appropriate offer psychological and social support as needed. Quality standards The following quality statements are relevant to this part of the pathway. Bipolar disorder, psychosis and schizophrenia in children and young people quality standard 4. Support for carers Bipolar disorder in adults quality standard 3. Involving carers in care planning Page 6 of 10

7 4 Children and young people No additional information 5 Recognition and referral in primary care Do not use questionnaires in primary care to identify bipolar disorder in children or young people. If bipolar disorder is suspected in primary care in children or young people aged under 14 years, refer them to child and adolescent mental health services. If bipolar disorder is suspected in primary care in young people aged 14 years or over, refer them to a specialist early intervention in psychosis service or child and adolescent mental health services team with expertise in the assessment and management of bipolar disorder in line with the recommendations in this pathway. The service should be multidisciplinary and have: engagement or assertive outreach approaches family involvement and family intervention access to structured psychological interventions and psychologically informed care vocational and educational interventions access to pharmacological interventions professionals who are trained and competent in working with young people with bipolar disorder. 6 Diagnosis, assessment and management in secondary care See Bipolar disorder / Diagnosing, assessing and managing bipolar disorder in young people in secondary care 7 Adults No additional information Page 7 of 10

9 Glossary Carer A person who provides unpaid support to a partner, family member, friend or neighbour who is ill, struggling or disabled. Depression The severity of bipolar depression is defined in line with the NICE pathway on depression as follows: mild depression few, if any, symptoms in excess of the 5 required to make the diagnosis, with symptoms resulting in minor functional impairment; moderate depression symptoms or functional impairment that are between mild and severe; severe depression most symptoms, with symptoms markedly interfering with functioning. Can occur with or without psychotic symptoms. Evidence-based manual Based on at least 1 randomised controlled trial published in a peer-reviewed journal showing effectiveness in reducing depression symptoms in bipolar depression or preventing relapse when used as long-term treatment in people with bipolar disorder. p.r.n. As required. Valproate Refers to 3 formulations of valproate available in the UK: sodium valproate, valproic acid and semi-sodium valproate. At the time of publication (September 2014), sodium valproate and valproic acid had UK marketing authorisation for the treatment of epilepsy. Semi-sodium valproate had a UK marketing authorisation for the treatment of acute mania and for continuation treatment in people who have had mania that has responded to treatment with semi-sodium valproate. Both semi-sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component. Sources Bipolar disorder (2014) NICE guideline CG185 Page 9 of 10

10 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 10 of 10

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